Research

Backed by an abundance of medical research, the Motivate approach has emerged from 35 years of scientific study. For more information and a more detailed examination of the science behind the philosophy of Motivate, we invite you to peruse our many resources including studies, media and articles about and by our team.

1Neurocognitive and Hormonal Correlates of Voluntary Weight Loss in Humans

Insufficient responses to hypocaloric diets have been attributed to hormonal adaptations that override self- control of food intake. We tested this hypothesis by measuring circulating energy-balance hormones and brain functional magnetic resonance imaging reactivity to food cues in 24 overweight/obese participants before, and 1 and 3 months after starting a calorie restriction diet. Increased activity and functional connectivity in prefrontal regions at month 1 correlated with weight loss at months 1 and 3. Weight loss was also correlated with increased plasma ghrelin and decreased leptin, and these changes were associated with food cue reactivity in reward-related brain regions.
However, the reduction in leptin did not counteract weight loss; indeed, it was correlated with further weight loss at month 3. Activation in prefrontal regions associated with self-control could contribute to successful weight loss and maintenance. This work supports the role of higher-level cognitive brain function in body-weight regulation in humans.
contact us for the full research at info@motivationminceur.ca

2The Role of Motivation in Weight Management: New Findings

We have made what we think is a major breakthrough in research on weight management, in our finding that there are two kinds of weight control motivation.
“Positive” motivation comes from the perception of the benefits of weight control and the pain from one’s current weight. “Negative” motivation comes from the perception that weight control involves a loss of pleasure and freedom, takes a great deal of effort, and has a low probability of success. These two kinds of motivation may play different roles in weight management at different time points.
For example, overweight people who have no intention and who are making no effort to lose weight will have a relatively low level of Positive motivation. Those with a high level of Positive motivation are more likely to have definite weight loss goals and intentions (e.g. to lose 10 pounds in the next month). Thus, Positive motivation may be an important determinant in the “initiation” of weight loss efforts. Positive motivation is what makes you want to do something.
On the other hand, the level of Negative motivation should be related to the strength and persistence of weight loss efforts. Someone with a low level of Negative motivation will be less frustrated and more satisfied with the process of weight control. Therefore, Negative motivation should be a good predictor of weight loss. Negative motivation is what makes you not want to do something.
This is what we have learned about Positive and Negative motivation in our recent analysis:
We found that the perceived benefits of weight control increase slightly over the first 5 weeks of treatment. At the same time, physical and psychological pain associated with weight decrease significantly. The net result is that Positive motivation stays about the same. Negative motivation decreased significantly over 5 weeks, with consistent decreases in feelings of “resentment,” “regret,” “doubt,” and “perceived effort.” The results for Positive and Negative motivation at Time 1 and Time 2 are presented in Figure 1.
The decrease in Negative motivation over 5 weeks was related to improvements in weight, eating habits (decrease in “uncontrolled eating”), depression and stress. However, we did not see any relationship between changes in Positive motivation and these other changes (see Table 1).
It seems that a key effect of treatment on motivation is to decrease Negative Motivation. Improvements in negative motivation are not only due to weight loss, but are primarily related to improvements in eating habits and emotional state. Weight loss treatment is not just about following a diet, but about improving psychological risk factors and maintaining a strong motivation.
How do we decrease Negative motivation? We learn to see the process of weight control in a more positive light. Instead of thinking about what you can’t have, think about the advantages and pleasures associated with what you can have. If you come to value eating small portions of tasty and healthy food, then it won’t seem like such a burden and there will be less negative thinking. Similarly, if you discover that exercise is fun and feels good your thoughts about exercise will be positive.
Motivation is an automatic emotional response (something that we feel) and in order to keep it strong, we have to work on our thoughts and perceptions. Daily, you should continue to think about the benefits of being at your healthy weight and making the right choices, and put a STOP to negative thoughts that are always unrealistic. Switch negative interpretations to positive ones, as follows: Instead of “It is too much of an effort to lose weight,” think “it’s too much effort to carry the extra weight”. Instead of “I resent having to follow a diet and change my eating habits,” think “I resent having to deprive myself of health, energy, youth, and a nice silhouette.” Rather than thinking “I regret not having the food I love,” think “I regret not being the human being I want to be”
.
Successful long-term weight management (losing the weight and keeping it off) is not just about trying to stick to a diet but learning to think and feel in less negative and more positive ways. This can easily be accomplished with the therapy tools that you have available to you, which you only need to do for a few minutes per day.
Stephen Stotland, Ph.D. & Maurice Larocque, M.D. August 2009

3Prediction of weight loss

RESEARCH UPDATE: Prediction of weight loss
We have recently analyzed results from 344 female patients during the first 9 months of their treatment. The following are factors which we found to predict the amount of weight lost during this period: (1) choosing a VLCD rather than a LCD, (2) early weight loss, (3) the number of assessments, and most importantly, (4) early improvement in eating behavior. Together, they make a very substantial difference in the treatment outcome! In the best case scenario there is a reduction of 7.4 BMI points, while the worst case scenario shows a gain of 1.3 BMI points.

4PROLONGED REFEEDING IMPROVES MAINTENANCE

Abstract
The aim of this study was to test the hypothesis that a prolonged re-feeding duration after successful VLED-induced weight loss beneficially affects weight development and eating behaviour. 269 patients were recruited to a one-year obesity treatment program with 12 weeks of initial very-low-energy diet (VLED). After VLED, patients with ≥10% weight loss were randomly allocated to one week (Group 1) or six weeks (Group 6) of re-feeding to an ordinary, energy-reduced diet, and thereafter followed and actively treated for an additional 40 weeks. Eating behaviour was measured with the revised Three-Factor Eating Questionnaire (TFEQ-R21) at baseline, during and after re-feeding, and at week 52. Weight change over time in the two treatment groups was tested by repeated measures analysis in completers and by intention-to-treat (ITT). 169 patients (109 women and 60 men) lost ≥10% during VLED and were randomised. At randomization, weight loss was −16.5 ± 3.7% in Group 1 and −16.7 ± 4.3% in Group 6 (P = 0.73). Between week 12 and 52, completers in Group 6 regained significantly less weight (3.9 ± 9.1%) as compared to Group 1 (8.2 ± 8.3%), (P = 0.006), (ITT, P = 0.05). Patients with six weeks of re-feeding maintained a higher level of dietary restraint after re-feeding was completed but eating behaviour did not differ significantly between the two groups at week 52. The results suggest that longer re-feeding duration after successful weight loss with VLED improves weight maintenance in a one-year perspective.

In Anne. E. Prescott (Ed.), The concept of self in medicine and health care. Nova Science Publishers, Hauppauge NY, 2006.
Self­regulation of weight: Basic processes and treatment implications
S C Stotland1, 2, M Larocque2, & I Kronick1
1Department of Psychology, McGill University, Montreal, Canada 2MLA Nutrition Clinics, Montreal, Canada
Address:
Dr. Stephen Stotland
1310 Greene Avenue, Suite 230 Westmount, Quebec H3Z 2B2 (514) 737­3360 sstot@qc.aibn.com
SELF­REGULATION OF WEIGHT 1
SELF­REGULATION OF WEIGHT 2 Abstract
The regulation of bodyweight is a complex process, with multiple biological, environmental and psychological factors playing a role. The primary treatment for obesity is modification of eating and exercise behavior, the success of which depends on the patient’s adherence to the behavior change plan, and therefore represents a problem of self­regulation. The failure of a large percentage of individuals to achieve their weight loss goals has led a number of authors to question whether or not bodyweight is amenable to effective self­regulation. However, psychological approaches to obesity have not integrated recent theoretical developments concerning self­regulation. The present paper will present a new model of weight control, which considers weight regulation as a broadly applicable, carefully sequenced, self­regulatory process occurring in the context of other goals and challenges, in particular the management of mood states and interpersonal relations. Data relevant to our model is presented, derived from a large sample of individuals in treatment for obesity.
Introduction
Obesity has received a great deal of scientific and popular attention in recent
years. The detrimental physical and emotional effects of obesity have been well documented (Fontaine, Redden, Wang, Westfall, & Allison, 2003; World Health Organization, 1998). However, while weight loss efforts are very common among overweight individuals (Meltzer & Everhart, 1996; Serdula, Mokhad, Williamson, Galuska, Mendlein, & Heath, 1999), only a small percentage reach or maintain a healthy weight (Jeffery, Drewnowski, Epstein, Stunkard, Wilson, Wing, & Hill, 2000; Wadden, Foster, & Brownell, 2002). Nevertheless, where successful, intentional weight loss appears to have positive effects in reducing disease and mortality (Gregg & Williamson, 2002). In view of the urgent need to develop more effective treatment methods, research designed to elucidate factors responsible for successful or unsuccessful weight loss outcomes is extremely important. The present chapter addresses this issue from a “self­ regulation” perspective.
Weight Regulation
When we talk about the self­regulation of weight, how difficult is the task one is
up against? How controllable is weight? As evidenced by the multitudes of perspectives and the huge amount of current research, it is clear that weight regulation is an extremely complex bio­psycho­social process. Genetic factors appear to exert a large effect, estimated to predict anywhere between 25% and 40% of actual weight (Bouchard, 1994; Price, 2002). Physiological processes influence eating by altering hunger and satiety mechanisms (Badman & Flier, 2005; Hellstrom, Geliebter, Näslund, Schmidt, Yahav, Hashim, & Yeomans, 2004). Environmental factors, including the available food and
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features of the social situation, are also powerful influences on eating (de Castro, 2004; Wansink, 2004). It is apparent that genetic and environmental variables interact, such that genetic predisposition combines with an “obesogenic” environment to determine obesity prevalence (Tremblay, Perusse, & Bouchard, 2004). However, such views appear overly “deterministic” when the role of self­regulation is ignored.
An understanding of weight self­regulation requires an analysis of eating and exercise self­regulation. This is so because weight can only be controlled, or “self­ regulated,” by controlling eating and exercise. Of course, one could theoretically take a medication that would result in a lower weight without a change in eating and exercise, but that would not be illustrative of “self” regulation, but a direct biological manipulation. Other drugs might cause weight reduction by altering eating or exercise, but this too would not be evidence of self­regulation, but a biological change. Certainly, such a change could have an effect on self­regulation, by making the task easier (i.e. by reducing hunger, increasing satiety, or increasing the drive and ability to move and engage in activity).
As physiological and social­psychological research demonstrates, not all self­ regulation is created equal – it may be more or less difficult, depending on biology and circumstances. In any case, self­regulation appears to require a certain amount of energy, or psychological resources, that may be “used up,” which can lead to self­regulatory failure (Baumeister, Bratslavsky, Muraven, & Tice, 1998). In fact, several authors have declared the task of weight self­regulation so difficult that it should be abandoned as a target of obesity treatment; it has been suggested that efforts to reduce the prevalence of obesity should focus exclusively on environmental and pharmacological intervention
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(Herman & Polivy, 2004; Jeffery, 2004; Lowe, 2003; Swinburn, Egger, & Raza, 1999; Wansink, 2004). In rejecting the feasibility of individual­focused intervention, these authors appear to reject the importance of self­regulation of eating, exercise and weight.
Lowe (2003) concludes that self­regulation is not up to the task of effective weight control, but rather that some of the answer to the obesity problem lies in helping people make changes in what he calls the “personal food environment.” Such changes might include reducing the “energy density” of the diet (increasing fiber and water content) and reducing the amount of contact with food and the number of eating choices one has to make by relying on prepackaged meals (meal replacements and prepared meals). However, although making changes in the food that one encounters and interacts with seems like an important strategy for weight control, it should be recognized that the implementation of the strategy is dependent on self­regulation. One of the ways that effective weight controllers accomplish weight self­regulation is by making changes in their environments to facilitate self­regulation. This is good problem solving, which is of course an important part of self­regulation as well.
The pessimistic tone of recent papers about individual change efforts is not characteristic of the attitudes of clinicians more generally, however, and treatment of the obese individual is still a very important target of medical and psychological intervention. Furthermore, overweight individuals continue to purchase and utilize a huge amount of commercial weight loss products, plans and programs – people evidently believe that weight can be self­regulated (i.e. they display an “internal” weight locus of control – Stotland & Zuroff, 1990). In fact, people generally possess a mixture of internal and external weight locus of control beliefs (Stotland & Zuroff, 1990). Thus, people tend to
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think that they have some degree of control over their weight, but that uncontrollable factors like genetics and luck also play a role. This kind of attitude means that the individual is very open to “treatments” that promise to increase self­control, or to make self­control less necessary. The paradox is that one looks to an external agent to supply internal control (see also, Polivy & Herman, 2002).
The popularity of weight control treatments indicates that individuals often do not feel they understand the problem or know how to solve it. They are reaching out for commercial or professional help to supply the answer, as well as needed support. However, recent analyses indicate that results for commercial (Tsai & Wadden, 2005) and professional (Wadden et al., 2002) treatment have been disappointing. The average weight loss over a number of years in studies that include long­term follow­up approaches zero (Wadden et al., 2002). The implications of such failures for psychological theories of obesity treatment have not been fully or adequately examined.
Early behavior therapy approaches towards obesity treatment (Stuart, 1967) were based on classical and operant conditioning principles and they attempted to modify behaviour by changing the environmental stimuli associated with maladaptive behaviour. Current behavioural programs utilize a variety of techniques derived from conditioning as well as cognitive theories (Foster, Makris, & Bailer, 2005). There is a growing consensus (Byrne, Cooper, & Fairburn, 2004; Jeffery et al., 2000) that psychological research has so far failed to provide an adequate explanation for why most people fail to maintain weight loss – this being the crucial problem in obesity treatment. The present chapter offers a self­regulation model of weight control as a framework for research and as a guide for the treatment of obesity.
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Self­Regulation
Self­regulation theories have become increasingly popular in health psychology
research (Maes & Karoly, 2005), but have not been well developed in relation to weight and eating. Self­regulation theories vary in emphasis, but generally include: goal-setting, planning, self-monitoring of outcomes, self-evaluation of progress relative to expectations, emotional response to outcomes, problem-solving when progress does not meet expectations, and emotion-control strategies (see Figure 1).
Self­regulation theories begin with the concept of “goal”. The goal is the reference point from which efforts and outcomes can be judged. Of course, there are a great variety of types of goals – goals may be easy or challenging, short­term or long­term, self­chosen or given to one, important or trivial, realistic or unlikely, stressful or relaxing, supported or alone, and perhaps even conscious or unconscious (Little, 1999).
Weight self­regulation occurs in the context of other goals that the individual is pursuing simultaneously. Consequently, the goals of maintaining emotional well­being or managing interpersonal relationships may at times conflict with weight goals. This may be for two reasons, (1) focusing on other goals may interfere with weight self­regulation, and (2) eating may serve emotional or interpersonal self­regulation functions that may conflict with weight self­regulation. Thus, when an individual is depressed, eating self­ regulation may be altered, as the individual is engaged in the high priority project of trying to feel better, and may choose to eat (or even overeat) as a means of doing so. To adequately understand eating and weight self­regulation, we need to identify how they fit into the bigger picture of self­regulation. This requires a “molar” level analysis of goals, such as the analysis of “personal action constructs” like personal projects (Little, 1999)
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and current concerns (Klinger, 1975). There has not yet been a comprehensive analysis of goal constructs in relation to eating and weight self­regulation.
The weight self­regulation sequence
Weight goals may include weight maintenance, weight loss or weight gain. Research indicates that participants in weight loss programs typically have unrealistic goals – while weight loss in such programs rarely exceeds 10% (considered a good outcome from the point of view of improving health), the average weight loss goal tends to be in the range of 20 – 35 % of starting weight (Foster, Wadden, Vogt, & Brewer, 1997). Several authors have suggested that helping patients adopt more realistic weight loss goals may improve maintenance (Byrne et al., 2004), although a recent test of this hypothesis produced equivocal results (Foster, Phelan, Wadden, Gill, Ermold, & Didie, 2004).
The process of goal­setting is addressed by a number of cognitive­behaviour theories. The motivation to pursue a goal is considered to be a function of its “value” (compared to alternatives), and the “expectancy” of being able to reach it (Feather, 1982). A variety of motivational variables relevant to goal­setting have been assessed in relation to weight control, including locus of control, outcome expectancy, self­efficacy and self­ determination (for a review, see Baranowski, Cullen, Nicklas, Thompson, & Baranowski, 2003).
Once a goal is established, self­regulation proceeds to a planning phase. The act of planning in weight self­regulation consists of deciding when and what to eat and where and when to exercise. Without plans, one is more likely to be influenced by situational factors, such as the kind of food that is available. For example, if one does not bring
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lunch to work and suddenly, at noon, is offered a share in the all­dressed pizza that work colleagues have ordered and that will arrive in moments, the probability of eating pizza is increased. One can learn to respond to such temptations with effective planned strategies. For instance, one could determine never to partake in fast food lunches at work, and
when offered to do so, to politely decline, and to go take a walk in search of some more balanced meal. Having a specific plan, or “implementation intention” (Gollwitzer, 1993), appears to increase the probability of healthy eating behaviour (Verplanken & Faes, 1999).
The most common weight loss plan is some form of structured diet. An obvious difference between various diet plans is in the rate of weight loss. For example, we found that “very low” calorie (e.g. 600 – 800 calories per day) diets resulted in greater short­ term (up to 9 months) weight loss compared to “low” calorie (e.g. 1000 – 1200) diets (Stotland & Larocque, 2005). Therefore, we were not surprised to find that when given a free choice of diets, a majority of participants chose very low calorie (60%) rather than low calorie diets (40%) (Stotland & Larocque, 2002), reflecting dieters’ desire for rapid weight loss.
Goal attainment may be monitored with various methods of self-monitoring, such as calorie counting, following a menu plan, or more subjective judgments (“I feel like I’m following the plan”), as well as weight change. Most weight loss programs teach participants some method of monitoring eating and exercise. A number of studies have shown that better adherence to behavioural self­monitoring predicts better weight loss outcomes (Boutelle & Kirschenbaum, 1998). However, although it is a helpful strategy, most people are not very diligent in monitoring eating (Womble, Wadden, McGuckin,
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Sargent, Rothman, & Krauthamer­Ewing, 2004), and quite inaccurate in reporting what they have eaten (Lichtman, Pisarska, Berman, Pestone, Dowling, Offenbacher, et al., 1992; Weber, Reid, Greaves, De Lany, Stanford, Going, Howell, & Houtkooper, 2001).
So how do people self­monitor their eating and exercise behaviour? How do we self­monitor states of hunger and fullness? How much awareness is there of “daily” consumption (i.e. not only what I’ve just eaten and how full I feel right now, but how much I’ve eaten for the day, how balanced my eating has been). Little information is currently available about how much attention people typically give to their eating, or about how such attention influences actual food intake.
The self-evaluation of dieting outcomes influences the motivation to continue. Weight change is the most important feedback for a dieter. Weight loss is highly rewarding and therefore rapid weight loss is a strong motivator to adhere to a diet. However, people on diets generally stop losing weight between 3 and 6 months from starting (Jeffery et al., 2000), and consequently very few reach their original weight loss goal (Foster et al., 1997). Given the undeniable logic of the energy­balance equation (Bray, 2002), it would appear that the primary reason that people stop losing weight is that they stop adhering to the diet plan, otherwise they would eventually reach (or come much closer to) their desired weight.
If one is still dissatisfied with one’s weight, why do continued weight loss efforts seem to have a diminishing reward value? Why do people slip back to old habits? The more dissatisfied one is with the weight loss result the more one should be motivated to achieve the lower weight goal, yet dissatisfaction with weight loss is associated with poorer weight loss maintenance (Foster et al., 2004). Perhaps it is because, as Bandura
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and Cervone (1982) showed quite some time ago, dissatisfaction is only motivating in combination with high self­efficacy. Only when one believes the goal can be achieved will one be motivated by feedback that the goal has not yet been reached. The tendency appears to be for dieters to blame themselves, attributing the poor result to a lack of effort and willpower (Polivy & Herman, 2002), which contributes to guilt feelings and a loss of self­efficacy.
Depending on the results of the earlier steps of the weight self­regulation sequence, the individual then engages in problem solving. Behaviour therapy programs typically include strategies for more adaptive problem solving (Foster et al., 2005). Here, one tries to figure out how to increase the probability of attaining the weight goal, and then whether the required effort is worth it. Little information is available concerning dieters’ problem solving. Anecdotally, the problem solving appears to consist of a vow to “be better tomorrow,” or worse, “start again on Monday.” Thus, there does not seem to be an adequate analysis of the cause of dietary failure. The simple admonition to “try harder,” is unlikely to produce better results.
If one feels that progress towards an important goal is too slow but success is judged to be still possible, one may feel frustrated but still motivated. On the other hand, if progress is slow and prospects are doubtful, then frustration will be mixed with anxiety, and if the poor results persist will lead to feelings of disappointment, sadness and eventually hopelessness (Carver, 2004; Vieth, Strauman, Kolden, Woods, Michels, & Klein, 2003). Dieting can have quite dramatic positive or negative effects on emotional state, depending on the weight loss outcome. Generally, problem­solving is enhanced by positive affect and disrupted by negative affect (Frederickson, 2001). Furthermore,
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numerous studies have demonstrated a link between negative affect and overeating tendencies (Canetti, Bachar, & Berry, 2002; Stotland & Larocque, 2004). Thus, the need for dieters to manage emotional states is evident.
Dieting vs. lifestyle modification
The expected long­term outcome of dieting (although the dieter may not acknowledge it consciously) is “stopping the diet” – no one plans to stay on a diet forever. There is an assumption that after the diet a change will have taken place in eating and exercise habits, so that maintenance of weight loss will be assured. Yet most dieters have less confidence in maintenance than they do in the achievement of the initial weight loss (Stotland & Larocque, 2005). Weak confidence in maintenance unfortunately is an accurate reflection of the typical outcome. Problems in maintaining weight lost may be due to the lack of effort put into meaningful behaviour change during a strict diet program.
At a minimum, dieters need to understand that maintenance is a separate goal from weight loss. Weight maintenance requires that one learn how to balance energy intake and output, which requires a modification of one’s former eating and activity patterns – this kind of behaviour change is often referred to as “lifestyle modification.” Diets represent a very different type of self­regulation than lifestyle modification – in lifestyle modification the goal is “healthy eating and exercise behaviour” which is expected to result in the eventual attainment and maintenance of a “healthy weight.”
An example of a specific behavioural goal in a lifestyle modification approach is learning to stop eating at a lower threshold of fullness, a goal that requires self­ monitoring and learning a new standard of fullness. If we look closely at the experience
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of eating less we see that the immediate result is simply feeling less full – the link with weight loss is delayed and must be taken on faith. Yet one can learn to appreciate feeling less full as a goal in of itself – this is a glass half full or half empty scenario; one may see eating less as a loss of pleasure, or feel good about eating “just the right amount.”
A study of weight control motivation
We measured weight loss goals and related motivational variables in 450 women
and 60 men who were participating in a medically­supervised diet program (Stotland & Larocque, 2005). A subset of these subjects (N=276) were assessed again after one month of treatment. We determined the weight loss goal by calculating the difference between current weight and desired weight, as a percentage of current weight. We then asked a series of 22 questions assessing weight control motivation (Table 1).
We defined weight control motivation as the sum of attitudes about current weight, desired weight and weight control. These attitudes reflect positive and negative outcome expectancies, self­efficacy, and response expectancy, which are central concepts in cognitive social learning theories of weight control motivation (Baranowski et al., 2003). Our objective was to create a brief scale that would be appropriate for clinical settings
and research requiring repeated measures analysis, where the issue of “user friendliness” is paramount, and the length of the scale is a primary consideration.
We considered various factor analytic solutions and concluded that a 3­factor model was the most meaningful, accounting for 40.3% of the variance in the items. Factor 1 items appeared to measure self­efficacy and response expectancy, and was labeled confidence & acceptability. Factor 2 included items related to attitudes about current weight and expected benefits of weight loss, and was labeled importance. Factor
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3 included items reflecting the frequency of thoughts about the goal, and was labeled positive goal activation.
Examination of Table 2 indicates that several motivation items showed somewhat limited variance. In particular, items related to the value of weight loss had means close to the maximum possible score. This is not surprising considering that the sample included only patients in weight loss treatment. As a consequence of the restricted range, the importance subscale had a somewhat low internal consistency. We would expect that evaluation of this scale in the general population, or in a non­treatment seeking obese sample would reveal more variability and higher reliability.
The three motivation scales showed an interesting pattern of correlations with other variables (Table 3). Our current research is exploring a number of unanswered questions, including changes in motivation over longer periods of time during treatment and outside of a treatment context, influences of treatment variables (e.g. therapeutic alliance measures) on motivation, and the causal relationship between motivation, other psychological variables (e.g. depression, stress) and weight changes.
Do only dieters engage in eating self­regulation?
In research on dietary restraint (Herman & Polivy, 1984; 2004; Ruderman, 1986), people are often grouped into “restrained” and “unrestrained” eaters, a categorization which is sometimes used interchangeably with “dieters” and “non­dieters.” Studies have tended to focus on mapping the cognitive structure of the high restraint group (the “dieters”) while ignoring those who are low on restraint (the “nondieters”). The assumption has been that unrestrained eaters regulate their eating in a much less cognitive
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manner, eating in accord with hunger and taste considerations and are therefore not thought to engage in eating self­regulation.
We investigated the cognitive processes underlying the decision to eat or not eat (Stotland & Kronick, 2005) in restrained and unrestrained college females. We used a trait measure of eating restraint, the Restraint Scale (Polivy, Herman, & Warsh, 1978) to measure general attitudes towards dieting, and we developed the Eating Thoughts Inventory to measure thoughts that one might have while deciding whether or not to eat some available food. The scale includes items measuring “restraint” thoughts (“No, I don’t want the cookies; I shouldn’t), “disinhibition” thoughts (“Yes, I want the cookies, what the hell”), and “appetitive” thoughts (“No, I don’t want the cookies, they don’t appeal to me”).
We found that eating thoughts were a better predictor than Restraint Scale scores of the decision whether or not to eat. Regardless of level of trait restraint, it was the combination of appetitive thoughts and restraint thoughts that predicted eating/not eating behavior. Even the unrestrained eaters reported a significant number of restraint thoughts and an even greater number of disinhibitive thoughts (which, by definition must firstly involve some level of dietary inhibition). From these results, it may be concluded that what determines whether or not individuals eat is not ultimately their everyday (trait) level of restraint, but rather the actual restrained and appetitive (and disinhibitive) thoughts they are having with regards to the food placed in front of them.
We believe that such eating thoughts constitute a form of active self­regulation – one that seems to be taking place in both restrained and unrestrained eaters alike. Indeed, a robust decision making process involving caloric, diet­abiding and taste­related factors
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seems to be at play, mediating food intake in all eaters. Our study thus shows that unrestrained eaters do self­regulate their eating, and are not purely driven by physical needs and desires.
Obesity treatment based on self­regulation theory
In our view, many obese patients would benefit from a better understanding of self­regulation in weight control. Individuals may need help at various stages of goal pursuit, from the decision making stage in which the pros and cons of beginning a weight loss attempt are evaluated and a specific weight loss goal is determined, the planning stage in which diet and exercise strategies are chosen, the action stage in which the plan is enacted, evaluated and modified, and during which one must persist despite stress and frustration, and the maintenance stage, with the ultimate goal of fully integrating the eating and exercise changes.
The self­regulation model describes the processes that guide the weight control process. Failure to achieve the goal may reflect problems in self­regulatory processes, or may be due to other factors interfering with self­regulation (see Figure 1). For example, metabolic adaptations to weight loss may make further weight loss more difficult (Weyer, Proatley, Salbe, Bogardus, Ravussin, & Tataranni, 2000). Negative affective states may reduce weight control self­efficacy and increase emotional eating tendencies (Stotland & Larocque, 2005). Social influences may make self­control more or less likely (Wansink, 2004). Clinicians should appreciate both the complexities of weight self­regulation and the larger context of the individual’s life.
The therapeutic attitude described as “autonomy supportive” (Williams, Deci, & Ryan, 1998) encourages the patient to make her own decisions about goals and strategies.
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Motivation is enhanced by emphasizing patients’ awareness of their goals and encouraging discussion of the consequences of their current behavioral choices, along with optimistic collaboration in the development of plans (Rollnick & Miller, 1995). As treatment progresses, self­efficacy is strengthened by helping the patient recognize incremental progress towards the goal or the success of a plan (Bandura, 2004). This is crucial, given the tendencies for dieters to feel dissatisfied and frustrated with their rate of weight loss and to focus on weight rather than behaviour change goals. All of these strategies are important in obesity treatment, because patients often have a significant amount of negative emotional expectancies about the process (Stotland & Larocque, 2005) and treatment drop­out rates are notoriously high (Davis & Addis, 1999).
In addition to therapeutic support, there is growing interest in the use of
interactive technology as self­regulation tools (Bandura, 2004), which are seen as methods to make treatment available to a much larger number of people, and add a new dimension to treatment in settings where patient­clinician contact is at a premium (e.g. primary care). In our own research we have been evaluating the usefulness of Internet­ based psychological assessment in the treatment of obesity (Stotland & Larocque, 2003). The Larocque Obesity Questionnaire (LOQ; Stotland & Larocque, 2004) is an on­line questionnaire which includes subscales measuring Uncontrolled Eating, Stress Responses, Depression, Perfectionism, and the recently added motivation scales. The questionnaire is brief (requiring 10 – 15 minutes) and is immediately scored, with visual, quantitative and text­based feedback provided. Patients are strongly urged to complete the test on a monthly basis, to evaluate changes and areas of difficulty.
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We believe that an on­line assessment and feedback system such as the LOQ should enhance effective self­regulation, and may therefore have value in improving treatment outcome. We liken this tool to the blood sugar measurements required for effective diabetes self­management – without some sort of objective feedback it is extremely difficult for patient and clinician to guide long­term weight control efforts. Although we have not yet tested it in a controlled experiment we have found that more frequent use of the system was associated with a lower treatment dropout rate during the first 4 1⁄2 months of treatment (Stotland & Larocque, 2003). The potential for on­line assessment and treatment in obesity is still largely untapped (see Womble et al., 2004).
Conclusion
According to a self­regulation model, individuals who try to reduce their weight
require effective goal setting, planning, self­monitoring, self­evaluation, emotional coping and problem­solving. In previous accounts of the behavioural treatment of obesity, many of these elements have been included in treatment plans (Foster et al., 2005), but there has been a lack of theoretical integration or a model that can be used to guide efforts to improve treatment outcome.
Our model places the self­regulation of weight, eating and exercise within a broader self­regulatory perspective, considering other goals that the individual is pursuing, and also recognizing the influence that physiological and environmental variables can have on self­regulation.
A number of theories have stressed the importance of stages, or phases, or periods, in self­regulation (e.g. Schwarzer, 1999). This is nowhere more necessary than in weight control. The management of obesity is a lifelong concern, and long­term studies are
SELF­REGULATION OF WEIGHT 18
required to even begin to appreciate the changes that occur over time in behaviour, motivation and weight.
The study of obesity and its treatment require a means of measuring and tracking self­regulation processes. This is an interesting situation in which the means for one group (the patients) to improve self­regulation of weight, by providing them with information relevant to their goals, is the same means for another group (the researchers) to evaluate the causes and effects of weight self­regulation processes. Interactive technology is a means of expanding the scope and access of research and clinical intervention.
Yet again, weight self­regulation can never be totally predictable, because it is influenced by other ongoing self­regulation projects. However, as we map out the self­ regulatory strategies of people showing different courses of weight change, response to diets, and adherence to treatment, we may be able to design a blueprint for more successful outcomes. A treatment model based on self­regulation maximizes patient responsibility and facilitates the doctor­patient relationship. By starting with an appreciation of self­regulatory processes, we may gain a better understanding of the difficulties that many people have with weight control, and a framework for developing a more effective treatment of obesity.
SELF­REGULATION OF WEIGHT 19
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SELF­REGULATION OF WEIGHT 27
SELF­REGULATION OF WEIGHT 28
Outcome expectancy
Self­efficacy, acceptability
Goal
Accesibility, activation
Planning
Self-monitoring
Socio­ environmental Facilitators & impediments
Physiology
Emotional state
Problem-solving
Self-evaluation & emotional response
Personality traits
Figure 1 – The self­regulation sequence and influences
Table 1 – Weight Control Motivation Questionnaire
1. RIGHT NOW, how important is it for you to succeed in weight control?
1234567
It’s not that Important compared To other goals in my Life
It’s the most Important. Goal in my Life
2. RIGHT NOW, how much physical pain is caused by your weight?
1234567
None A great deal
3. RIGHT NOW, how much emotional pain is caused by your weight?
1234567
None A great deal
4. RIGHT NOW, do you believe you will be healthier if you lose weight?
1234567
I do not
Believe I
Will be any healthier
I believe I Will be much Healthier
5. RIGHT NOW, do you believe you will be happier if you lose weight?
1234567
I do not
Believe I
Will be any happier
I believe I Will be much Happier
6. RIGHT NOW, how do you feel about having to deal with weight control and trying to maintain healthy (eating and exercise) habits?
1234567
I don’t mind I totally It at all Resent it
7. RIGHT NOW, how much effort do you feel it will take to succeed in weight control?
1234567
A little effort A huge effort
8. RIGHT NOW, how much effort are you willing to make in order to reach your desired weight?
1234567
Hardly any Whatever it takes
SELF­REGULATION OF WEIGHT 29
9. RIGHT NOW, how confident are you that you will reach your desired weight?
1234567
I’m afraid I I’m sure I Will fail Will succeed
10. RIGHT NOW, how confident are you that you will maintain the weight you lose?
1234567
I’m afraid I Will regain All of it
I’m sure I Will maintain All of it
DURING THE PAST WEEK, how often did you do each of the following:
11.
12.
13.
14.
15.
16.
Imagined myself at my desired weight.
123456
never once or a few times every day a few times many times
twice per day per day per day
Told myself that life is short and I deserve to please myself by eating whatever I
want.
123456
never once or a few times every day a few times many times
twice per day per day per day
Felt doubtful about succeeding in weight control.
123456
never once or a few times every day a few times many times
twice per day per day per day
Talked to someone who made me feel discouraged about losing weight.
123456
never once or a few times every day a few times many times
twice per day per day per day
Thought about the benefits of losing weight.
123456
never once or a few times every day a few times many times
twice per day per day per day
Felt regretful about all the things I must give up in order to lose weight (e.g., foods I like, old and comfortable habits, favorite restaurants, parties, etc.).
123456
never once or a few times every day a few times many times
twice per day per day per day
SELF­REGULATION OF WEIGHT 30
17. Read or listened (TV, radio, tapes, books and Internet) to inspiring material about weight loss.
123456
never once or a few times every day a few times many times
twice per day per day per day
18. Reminded myself that I will reach my weight loss goals if I am persistent.
123456
never once or a few times every day a few times many times
twice per day per day per day
19. Felt guilty about my weight (or my overeating).
123456
never once or a few times every day a few times many times
twice per day per day per day
20. Read or listened to something that made me feel discouraged about losing weight.
123456
never once or a few times every day a few times many times
twice per day per day per day
21. Talked about weight loss strategies with a supportive person (friend, advisor, doctor).
123456
never once or a few times every day a few times many times
twice per day per day per day
22. Thought that trying to lose weight was too big of an effort.
123456
never once or a few times every day a few times many times
twice per day per day per day
SELF­REGULATION OF WEIGHT 31
Table 2 – Weight Control Motivation Questionnaire means, standard deviations and reliabilities at time 1 (pretreatment) and time 2 (1 month after start of treatment)
SELF­REGULATION OF WEIGHT 32
Scale & Items
Time 1
Time 2
t275
Mean
SD
!
Mean
SD
!
Confidence & Acceptability
56.5
8.8
.79
64.2
7.8
.82
­15.3***
61
5.0
1.7
5.6
1.4
­6.3***
9
5.2
1.8
6.0
1.4
­7.8***
10
4.2
1.9
5.3
1.5
­10.3***
121
5.0
1.1
5.6
0.7
­7.9***
131
4.3
1.2
5.0
0.9
­9.9***
141
5.6
0.8
5.8
0.5
­4.9***
161
4.3
1.2
5.0
0.9
­11.7***
191
3.5
1.6
4.7
1.4
­11.0***
201
5.5
0.9
5.8
0.5
­4.9***
221
5.1
1.0
5.7
0.7
­8.1***
Importance
38.6
5.4
.69
35.6
5.4
.60
3.7***
1
5.8
1.1
5.7
1.1
0.6
2
3.0
2.0
2.5
1.6
4.6***
3
5.0
1.8
3.9
1.9
9.6***
4
6.6
0.9
6.4
1.2
2.1*
5
6.3
1.1
6.2
1.2
1.4
7
5.6
1.5
4.6
1.7
9.6***
8
6.3
0.9
6.3
1.0
0.1
Positive Goal Activation
15.4
4.2
.65
17.0
4.4
.76
­6.4***
11
3.2
1.4
3.7
1.3
­6.1***
15
4.3
1.2
4.3
1.2
0.2
17
2.1
1.2
2.4
1.1
­3.6**
18
3.2
1.5
3.9
1.3
­7.6***
21
2.6
1.0
2.7
1.1
­1.1
*p< .05 **p< .001 ***p< .0001
Note – 276 of the original sample of 510 patients completed a second psychological assessment
1 ­ item is reverse scored
Table 3 – Correlations between weight control motivation scales and age, body mass index and psychological variables
SELF­REGULATION OF WEIGHT 33
Variable
Confidence & Acceptability
Importance
Positive Goal Activation
Age
.19***
­.03
­.06
Body Mass Index
­.18***
.36***
.03
Weight Loss Goal1
­.24***
.36***
.09
Uncontrolled Eating2
­.58***
.25***
­.08
Stress Responses2
­.37***
.35***
­.01
Depression2
­.43***
.29***
­.01
Perfectionism2
­.35***
.22***
.06
Autonomous Motivation3
.15
.28*
.22*
Controlled Motivation3
­.43***
.33***
­.03
Perceived Health Threat4
­.30**
.34***
.05
Outcome Expectancy4
­.09
.13
.06
Action Self­ Efficacy4
.44***
.09
.21*
Coping Self­ Efficacy4
.34***
.19*
.13
Intention4
.25**
.19*
.32**
*p< .05 **p< .001 ***p< .0001
1 – Represents desired weight loss as a percentage of starting weight
2 – Larocque Obesity Questionnaire (Stotland & Larocque, 2004) subscale
3 – Treatment Self­Regulation Questionnaire subscale (Williams, Grow, Freedman, Ryan,
& Deci, 1996)
4 – from Schwarzer & Renner (2000)

Response to debate in Canadian Family Physician, May 2012 Should obesity be treated?
Stephen Stotland, Ph.D. & Maurice Larocque, M.D.
In reading the debate in the recent issue of Canadian Family Physician, we were astonished and disappointed, both as clinicians and researchers, to discover strong attitudes suggesting that obesity should not be treated. We found it particularly alarming that doctors should feel so hopeless and no doubt transmitting this frustration to their patients. Thus, we are concerned that numerous obese individuals will be discouraged from taking better care of themselves. This essay examines the basis for hopefulness in obesity treatment research, considering the results of our own research program.
In thinking about whether or not obesity should be treated we considered the impact of the well-documented negative bias among health professionals, including physicians, nurses, psychologists, dietitians and others, against obese people and negative attitudes toward the subject of weight management. The obese individual is blamed for the problem and is thought to be perhaps less deserving of care. Such biases, implicit and explicit, have been shown time and again.1
It is our opinion that those offering far-reaching conclusions about whether obesity “should” be treated2, 3 need to recognize the possibility of their own negative bias towards the obese patient and the weight management process. Negative attitudes in practitioners may be linked to their feeling ill-equipped to conduct this type of counseling.4 It is unknown to what extent practitioners are conscious of such feelings of low self-efficacy.
Doctors very frequently prescribe healthy behavior like better eating, exercise and stress reduction.5, 6 In fact these are the fundamentals of weight management. Do doctors have greater self-efficacy for influencing health behaviour than they have for influencing weight management? There is a paradox if doctors recognize and support the practice of healthy behavior (eating, exercise, substance use, stress, mood, sleep), but dismiss the likelihood of successful weight management, because if an obese person improves on these health behavior dimensions isn’t it a virtual certainty that they will lose weight?
Most of the available obesity treatment research has looked at outcomes primarily in terms of weight change, with insufficient attention to concurrent changes in behavior, attitudes and emotions, and there is almost no consideration of treatment “process.” What is needed is a theory-based account of how processes lead to weight control outcomes, over time. Without a strong theory, if we observe a negative outcome there is no way to use this information to engineer better treatments. Our research is an example of a more theoretically-based approach, an analysis of process and outcome in weight management based on a reliable set of measures of
Should obesity be treated?
1
psychological variables and the therapeutic alliance, as well as BMI and other physiological variables.
If the outcome of obesity treatment is very poor, as some believe, then we must try harder to understand why results are as they are, and develop a better theory that will predict more successful outcomes. This is not the time for hopelessness. In order to develop and test such a theory, we need studies with multiple observations over time and conditions. This type of research design is a perfect fit for obesity treatment, which involves ongoing treatment visits and assessments over a long period of time. In recent years we have used this type of repeated measures design, employing a multi-level modeling analysis to show:
(1) early (approximately one month) improvements in both weight and eating habits (less uncontrolled eating) predict better later weight changes (up to 9 months).7 This indicates we must pay very close attention to the early treatment results;
(2) changes in “negative” weight control motivation (feelings of resentment, regret, doubt and effort) are related to changes in weight and improvements in eating behavior and mood, while “positive” weight control motivation (beliefs that weight is causing physical or emotional suffering, and expectations that better weight control will have physical or emotional benefits) is not associated with weight or psychological changes.8 It is clear that the negative motivation dimension must be a focus of treatment research;
(3) improvements in psychological variables (eating, depression, stress, perfectionism, negative motivation) are related to improvements in the therapeutic alliance between clinician and patient; the alliance is related to weight loss outcomes, but this effect is fully mediated by changes in psychological variables. Thus, the alliance directly influences the patient’s mood and behaviour, which is then directly related to weight change.9
Our combined body of research leads us to conclude that the outcomes of weight control treatment are more predictable than previously believed (see also10). This research brings needed optimism for practitioners deciding to venture into the field of helping people with their weight. Patients often feel hopeless about weight control and are seeking support from their doctors and therapists. We must practice hope, as we continue to do theory-driven research to try to better understand the processes of weight control failure and success.
We were motivated to write this response to counter what we saw as a particularly negative viewpoint that some (but not all11) professionals seem to have about obesity treatment. We believe it is important to promote a stronger commitment to treat this problem. Our research shows that some of the causes of success and failure are controllable, such as helping patients to address their negative attitudes about the weight control process and working to establish a good working alliance. In this regard we would point at that our research shows it is not the initial levels of psychological variables (e.g. depressed mood, emotional eating) or the alliance that predicts outcome, but “changes” in these variables. Patients improve (and backslide) in all of
Should obesity be treated?
2
these dimensions simultaneously, which shows that practitioners must be sensitive to such changes. If we accept the premise that lifestyle change is possible, although a difficult, variable and long-term process, we are likely to achieve better outcomes. Surely we must not stop trying to better understand weight control, as we work to develop better ways to help individuals improve all of their health behaviour.
Should obesity be treated?
3
References
1. Puhl, R.M., & Heuer, C.A. The stigma of obesity: A review and update. Obesity 2009, doi:10.1038/oby.2008.636.
2. Ladouceur, R. Should we stop telling obese patients to lose weight? Canadian Family Physician 2012, 58, 499.
3. Havrankova, J. Is the treatment of obesity futile? Canadian Family Physician 2012, 58, 508- 510.
4. Greenwood, J.I.J. The complexity of weight loss counseling. J Am Board Fam Med 2009, doi: 10.3122/jabfm.2009.02.080256.
5. Foster, G.D.,Wadden, T.A., Makris, A.P., Davidson, D., Swain Sanderson, R., Allison, D., & Kessler, A. Primary care physicians’ attitudes about obesity and its treatment. Obes Res 2003, 11, 1168-1177.
6. Phelan, S., Nallari, M., Darroch, F.E., & Wing, R.R. What do physicians recommend to their overweight and obese patients? J Am Board Fam Med 2009, 22:115–122.
7. Stotland, S., & Larocque, M. Early treatment response as a predictor of ongoing weight loss in obesity treatment. British J of Health Psych, 2005, 10, 601–614.
8. Stotland, S., Larocque, M., & Sadikaj, G. Positive and negative dimensions of weight control motivation. Eating Behaviors 2012, 13, 20–26.
9. Larocque, C., Stotland, S., Larocque, M., Lecomte, C., Savard, R., & Sadikaj, G. Therapeutic alliance, psychological variables and outcome in obesity treatment. (In preparation).
10. Stubbs, J., Whybrow , S., Teixeira, P., Blundell, J., Lawton, C., Westenhoefer, J., ...& Raats, M.
implications for weight control therapies based on behaviour change. Obesity Reviews
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Problems in identifying predictors and correlates of weight loss and maintenance:
2011, 12, 688-708.
11. Moyer, V.A. Screening for and Management of Obesity in Adults: U.S. Preventive Services
Task Force Recommendation Statement. Ann Int Med 2012, 157, 1-6.
4

9Positive and negative dimensions of weight control motivation

Abstract
This study examined weight control motivation among patients (N = 5460 females and 547 males) who sought weight loss treatment with family physicians. An eight-item measure assessed the frequency of thoughts and feelings related to weight control “outcome” (e.g. expected physical and psychological benefits) and “process” (e.g. resentment and doubt). Factor analysis supported the existence of two factors, labeled Positive and Negative motivation. Positive motivation was high (average frequency of thoughts about benefits was ‘every day’) and stable throughout treatment, while Negative motivation declined rapidly and then stabilized. The determinants of changes in the Positive and Negative dimensions during treatment were examined within 3 time frames: first month, months 2–6, and 6–12. Maintenance of high scores on Positive motivation was associated with higher BMI and more disturbed eating habits. Early reductions in Negative motivation were greater for those starting treatment with higher weight and more disturbed eating habits, but less depression and stress, while later reductions in Negative motivation were predicted by improvements in eating habits, weight, stress and perfectionism. Clinicians treating obesity should be sensitive to fluctuations in both motivational dimensions, as they are likely to play a central role in determining long-term behavior and weight change.
Highlights
► We identified two relatively independent dimensions of weight control motivation. ► The value of weight control fluctuates with recent weight change and depression. ► Negative motivation fluctuates with changes in eating habits, weight, and stress. ► Motivation should be assessed repeatedly during weight control treatment.

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